The Vitality Center

Paul C. Dillon, M.D. & Paul E. West, III, PA-C

Anti-Aging Questionnaire

 +
Gender *
Please answer YES or NO to the following options that apply to you.
1) Are you tired throughout the day? *
2) How many hours of sleep do you get a night? *
3) Are you tired in the mornings? *
4) Do you have to drink caffeine to feel energized? *
5) Do you have to take supplements to feel energized? *
6) Do you feel like you can’t exercise or play sports like you used to? *
7) Does it take you longer to recover from a workout? *
8) Are you forgetful? *
9) Do you feel like your life is stressful? *
10) Do you struggle with having “enjoyment in life”? *
11) Do you have a good “work-life balance”? *
12) Is your sex drive lower than it used to be? *
13) Are you and your partner fulfilled when it comes to your sex life? *
14) Are you able to orgasm? *
Males only: Do you have trouble getting or maintaining an erection? *
Please select one or more symptoms that occur frequently or disrupt your lifestyle: *
15) Is weight an issue for you? *
16) Have you recently lost weight? *
17) Have you recently gained weight? *
18) Do you exercise? *
19) Have you experienced a decrease in or inability to maintain muscle mass? *
20) Have you tried any programs or medications to help lose weight? *
21) Do you feel like you eat a well-balanced diet? *
22) Are you happy with the way you eat? *
23) Do you have an issue controlling cravings? *
24) Do you have trouble feeling full? *
25) Do you eat more when you are stressed? *
26) Have you had any recent changes in your stool? *
27) Do you feel like you have trouble digesting certain foods? *
Powered byFormsite